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i6°°-r Waste Tire Suve Inspection Ike or In ction Report Number <br /> ■ y p ' _ ■ <br /> �!� State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 l 4 - 1 0 ! 58� <br /> California Integrated Waste Management Board - <br /> ?art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details <br /> ---- . <br /> TPID- L,� =I - <br /> OInspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^c If Referral,choose referral type(Fill one) <br /> Identifier: , , L' Y1 fit.Jti 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> IA <br /> Physical Address p <br /> Oso t� ��- �` -- -- - <br /> Street <br /> C24 92Inspection Date K51 DE � Q <br /> I (� Time In Time Out <br /> Cii�;� State Code a­ <br /> 0 <br /> -] QPM �_ O PM <br /> AM <br /> q V Lj <br /> Business Rep Title 0 AM{ { <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) "Fill all that apply)'�� (Fill all that apply) (Fill all that apply)' <br /> The Cr�ulni(Wfiore1F�TEj <br /> r Active Q Passenger ` Q Generator Q Outdoor <br /> D Q Closed O Altered <br /> GPS Latitude ��� . � Q Hauler Q Indoor <br /> -rte D Q Inactive Q Truck <br /> Longitude 0Planned Q OTR Q End Use Q Container <br /> � +< .��� <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q--Gar Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (6 Other t," 4,I p� r <br /> I c t/rf f9 Jlv '.. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m I M <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q ,@ 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q :Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: -- <br /> Comments jj - <br /> } f)t 7 itlr f(�l�t all ('V1 �!' �T,'� ✓F G'11� ��E�r-/� Ul f)i^ Wydliyrjj Ti; <br /> "VUI U(_71 <br /> S V i(-e >_/Y 0 i j'j 7A,e (IAA✓i rII t L;t'(fl G r t t L� tN i::'�-�(i f i I ( ► illi v�l ( y /�yv'1 ✓Cj I C a <br /> if P?o f 1:� /f Oh I l r_ 71/sr, <br /> rpt 1 -t i r M 1`� CC,1 i �S'15,1 <br /> 1'. <br /> Inspection Form Included: a' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 0EJ 1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 1 <br /> I <br />